Acrobat
MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Preterm Labor and Preterm Premature Rupture of Membranes
Sponsored by The Indian Health Service Clinical Support Center
3. Management and Prevention Guidelines
Case 3
E. J. E., a 25 y/o G2P0 at 23 weeks by her dates consistent with a 10 week ultrasound, presents with a history of low back pain and “pressure down there” for the last 24 hours. This has been accompanied by a copious clear vaginal discharge that has now become slightly blood tinged over the last hour. She denies uterine contractions and has no urinary tract symptoms. She has a history of a “LEEP” procedure for moderate dysplasia two years ago and an elective termination 10 years ago.
Management Guidelines
Since the etiology of idiopathic preterm labor remains cryptic despite extensive investigation, management remains suboptimal. A review of the evidence does reveal what does and what doesn't work well however. But first, how do you decide if your patient is in true preterm labor (PTL), or is just experiencing the “premature onset of contractions” (“POOC”)?
Should she be admitted, transported, or discharged home?
You also have to decide how early is too early for your institution . Most level II and III centers will not intervene at all at 34, or even 32, weeks, but that may not be true for your facility. The incidence of any type of infant respiratory distress syndrome (IRDS) is about one per cent after 36 weeks, but some sort of transient respiratory assistance, such as supplemental oxygen, and in rare instances a ventilator, may be necessary in up to 15-20 per cent of infants born at 34 weeks. Infant nutritional requirements, issues of thermostability , and available personnel to care for a premature infant are all important considerations.
Your own facility should have its own guidelines. Here are some PTL template guidelines to get you started.
Use of progesterone in prevention
Some newer investigations have pointed out the possible utility of progesterone preparations as a preventive measure for recurrent preterm birth in the subset of women with a history of one or more prior spontaneous preterm births.
ACOG has now given qualified approval to this strategy. ( See ACOG Committee Opinion Number 291, November 2003)
Here is one approach (See Progesterone Guidelines)
Eligible Patients:
- Asymptomatic women with a documented history of one or more prior spontaneous preterm births (less than 35 weeks gestation) who are identified prior to 24 weeks gestation, who are dated by ultrasound prior to 24 weeks, and who agree to return for weekly injections from 24 to 34 weeks of pregnancy.
- Consult with Maternal Fetal Medicine to establish eligibility and monitor outcomes.
Ineligible Patients:
- Women with a history of prior preterm birth due to a known cause such as a uterine malformation or cervical insufficiency requiring cervical cerclage.
- Women who present with symptoms of preterm labor (symptomatic uterine contractions, short cervix on ultrasound, uterine bleeding, ruptured membranes) after 24 weeks gestation.
- Women with a multi-fetal gestation.
- Women with a known fetal anomaly.
- Women with a prior indicated preterm birth (as a result of severe preeclampsia, placenta previa, placental abruption, fetal demise, or threatening maternal medical illness).
Drug Treatment Protocol:
- Weekly intramuscular injection of 17 hydroxyprogesterone caproate (17P) 250 mg* from 24 to 34 weeks of gestation.
- Fetal growth ultrasounds every 4 weeks while the patient is being treated.
Outcomes for Quality Assurance:
- Incidence of preterm birth prior to 35 weeks.
- Infant weights and Apgar scores.
- Incidence of preterm labor requiring inpatient treatment but not resulting in preterm birth.
- Any adverse maternal effects while receiving the therapy.
